How should I treat and manage a patient in a skilled nursing facility for short‑term rehabilitation who has a reactive hepatitis C antibody and an invalid hepatitis C virus ribonucleic acid test?

Management of Reactive HCV Antibody with Invalid HCV RNA Test

Repeat the HCV RNA test immediately using a new blood sample, as an invalid result cannot determine whether your patient has active hepatitis C infection requiring treatment. 1

Immediate Next Steps

Repeat HCV RNA Testing

• Obtain a new venipuncture blood sample and submit for HCV RNA testing using an FDA-approved NAT assay. 1
• The invalid result may be due to specimen handling issues, storage problems, or technical laboratory errors—none of which provide diagnostic information about infection status. 1
• CDC guidance explicitly recommends repeat HCV RNA testing when there is concern regarding handling or storage of the test specimen. 1

Why This Cannot Wait

• A reactive HCV antibody indicates one of three possibilities: current active infection, past resolved infection, or false positivity. 1
• Only HCV RNA detection can distinguish between these scenarios and determine if treatment is needed. 2
• Untreated chronic HCV infection leads to cirrhosis, hepatocellular carcinoma, and death, while modern direct-acting antivirals achieve viral clearance in over 95% of patients. 2

Interpretation Based on Repeat HCV RNA Result

If HCV RNA is Detected (Positive)

• This confirms current, active HCV infection. 1, 2
• Link the patient immediately to medical care for treatment evaluation. 1, 2
• Before initiating antiviral therapy, retest HCV RNA in a subsequent blood sample to confirm positivity. 1
• Test for hepatitis B before starting HCV treatment, as HBV reactivation can cause fulminant hepatitis and liver failure in coinfected patients. 2
• Perform HCV genotype testing and quantitative HCV RNA to guide treatment selection. 3

If HCV RNA is Not Detected (Negative)

• This indicates no current HCV infection—either past resolved infection or false-positive antibody. 1, 4
• No treatment is required. 4
• The patient is not infectious and does not require isolation precautions. 4
• No further action is needed in most cases. 1, 4

Special Considerations for Your SNF Patient

When to Consider Additional Repeat Testing

Even if the first repeat HCV RNA is negative, consider a second repeat test if: 1, 4

• The patient had potential HCV exposure within the past 6 months (recent injection drug use, recent blood exposure, recent tattoos/piercings)
• Clinical evidence of liver disease is present (elevated transaminases, jaundice, hepatomegaly)
• The patient is immunocompromised (HIV infection, immunosuppressive medications, organ transplant)

Infection Control in the SNF Setting

• While awaiting repeat HCV RNA results, use standard precautions only. 4
• HCV is transmitted through blood exposure, not casual contact. 5
• No special isolation or room assignment is needed. 4

Common Pitfalls to Avoid

• Do not assume the patient is HCV-negative based on an invalid RNA test—this provides zero diagnostic information. 1
• Do not order supplemental HCV antibody testing at this stage—it will not clarify whether active infection is present. 1
• Do not delay repeat RNA testing—incomplete testing is a major barrier to HCV elimination, with historically one-third of patients having incomplete testing. 6
• Ensure single-visit sample collection for the repeat test to avoid loss to follow-up. 6

Reporting Requirements

• If the repeat HCV RNA is positive, this is a reportable condition to your local health department in most jurisdictions. 1
• Check your state's specific reporting requirements for hepatitis C. 1